Sexual risk behavior among older adults

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Data show that older adults are being treated for a greater number of sexually transmitted diseases (STDs)—especially HIV—than in the past.1 According to recent literature and the CDC, older adults are engaging in more sexual activities despite previous beliefs that such activity declines with age.2 By 2015, the number of people aged 50 years and older living with HIV/AIDS will account for half of all individuals with the disease in the United States. This development is partially attributable to advances in highly active antiretroviral therapy (HAART). Individuals with HIV/AIDS who are taking HAART medications are living longer than those in previous years. However, risky sexual behavior is another reason for this increased incidence of HIV in the older adult population. Health-care providers must be cognizant of this trend and use it to shape their daily clinical practice, namely by routinely assessing and screening for STDs and educating older adults about such STD-protective behaviors as using condoms.

Contributing factors

The CDC reported that the highest prevalence rate of HIV diagnoses in 2008 was among persons aged 45 to 54 years. In 2011, the population with the highest percentage of people diagnosed with HIV was persons aged 55 years and older.2 The reason for the high prevalence of STDs in this group has not been examined fully in the literature. However, a great deal of research data show that older adults are engaging in more sexual activity than previously thought.3 In fact, many older adults are continuing sexual activity throughout their lifespan.

In a study of 3,005 older adults in the United States, current sexual activity was reported for 73% of those aged 57 to 64 years, 53% of those aged 65 to 74 years, and 26% of those aged 75 to 84 years.4 In addition, the population of individuals older than age 50 years who are single due to divorce or the death of a spouse or significant other is increasing.5 These two documented trends support the perception of increased sexual activity in older adults and the need for reinforcement of safe-sex practices over the lifespan.

For the purposes of this article, sexual risk behavior is defined as "sexual intercourse without condom use with a casual partner, and/or sexual intercourse without condoms with a new main partner with no prior HIV testing."6 Sexual risk behaviors can result in such negative health outcomes as emotional and social disturbances as well as the transmission of STDs. Since older adults are engaging in riskier sexual behaviors, health-care providers need further education regarding routine assessments of sexuality, risks of STDs, and methods of prevention. Table 1 offers an outline to help evaluate sexual risk in older adults.

• I discuss sexual activity with all of my patients because it is an important part of their medical care.

Broaching the topic

• Tell me about your sex life.
• When you say you've had sex, what exactly do you mean?
• Do you have sex with men, women, or both?

Asking about partners

• Tell me about the number of sex partners within the past three months.
• Where do you meet your partners?
• Have you ever gone online to meet partners for sex?
• How well do you know your sexual partners?
• What do you know about the HIV status of your partners?
• How does your partner's HIV status affect your sexual behavior?
• Have you noticed symptoms in your partner that are concerning for you?

Asking about sexual activity

• What sexual activities do your sexual partners engage in?
• Do you have oral sex? Vaginal sex? Anal sex?
• Do you select partners based on HIV status?
• Do you ever get drunk or high before you have sex?

Asking aboutprevention methods

• What do you do to protect yourself during sex?
• Do you use condoms when having sex? How often? With what types of sex?
• What has been your experience with using condoms?
• What factors/situations get in the way of using condoms?

Adapted from Centers for Disease Control and Prevention (CDC); Health Resources and Services Administration; National Institutes of Health; HIV Medicine Association of the Infectious Diseases Society of America. Incorporating HIV prevention into the medical care of persons living with HIV. Recommendations of CDC, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep. 2003;52(RR-12):1-24. Available at www.cdc.gov/mmwr/preview/mmwrhtml/rr5212a1.htm, accessed March 15, 2013.

Prevention challenges

The issue of risky sexual behaviors among older adults is multidimensional. Contributing factors include a growing population of older adults, increased longevity, better access to medical care, more availability of treatments for various types of male and female sexual dysfunction, inadequate knowledge and perception of being at risk for STDs, diminished need to protect against unintended pregnancy, and increased societal acceptance and acknowledgement of sexual behaviors in this population.

The current population of older adults has been described as "a sexually liberated Baby Boomer generation."7 A growing rate of older adults without major health impairment is contributing to the improved longevity of this population.8 In one study, older adults who reported poor physical health tended to have a decreased interest in sex.3 Another study examined the results of the 2001 report of the National Advisory Council on Aging, which stated that 92% of survey participants considered sex an important part of life.1 In addition, 75% of those aged 65 to 74 reported being sexually active.1 It is safe to assume that a greater number of older adults in better physical health will result in increased interest in sex.

More and more older adults are seeking medical care for such conditions as erectile dysfunction in men and postmenopausal atrophic conditions in women. Since the advent of sildenafil (Viagra) in 1998—as well as other phosphodiesterase inhibitors, penile injections, vacuum devices, and prostheses— research has shown an increase in the number of men continuing intercourse into their 80s.3 Topical vaginal estrogens and testosterone for vulvovaginal atrophy have led to fewer sexual pain and lubrication issues for many postmenopausal women.3 Since postmenopausal women do not have to worry about unintended pregnancy, they may choose to engage in unprotected intercourse, putting themselves at higher risk for STDs.9

A 2003 study determined that the perception of risk for STDs among older adults is minimal compared with that of adolescents and young adults.7 Older adults were less likely than younger adults to know how HIV is transmitted and were less knowledgeable about HIV disease progression. A 2008 study assessed for knowledge of STD risk in 165 educated men and women older than age 50 years: A total of 92% of study participants agreed that condoms prevented STDs and AIDS, indicating some level of knowledge of the connection between prevention of STDs and AIDS, but only 13.3% always wore condoms with intercourse.9 Despite the fact that data are limited regarding late-in-life sexuality (especially in assisted-living and nursing homes), a 2011 study of older people in care homes found that these adults do not lose interest in sex but feel limited by staff attitudes and other physical or environmental constraints.10 This increases the likelihood that any sexual activity among these individuals will be unprotected.

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